Don’t pine for the old Marcus Welby system of health care. It encouraged too many procedures and tests, which, believe it or not, are just as dangerous as getting too little care. But don’t be a casualty of managed care’s cost-cutting fixation, either. Here are some strategies for protecting your health and challenging an HMO’s denial of care.
Secure Your Medical History: Why are doctors and nurses the only ones who get to see your medical record? Find out what they’re scribbling. Ask for a copy of the clinic notes every time you see a doctor. Request an amendment if the doctor’s comments don’t reflect your concerns or questions. You’ll learn more about your health and be better prepared for future visits. And the record you assemble will be your best weapon if you ever need to challenge a plan’s decision. You should also keep a log of every other interaction with your plan. Even if it’s just a telephone conversation, write down the date, the name of the person you consulted and what you were told.
Turn Your Doctor Into an Ally: Everyone knows that HMOs often give doctors financial incentives to keep medical costs down. But money is just one of their tools. Bureaucratic hurdles, psychological pressure and restricted lists of laboratories and specialists are some of the other levers that plans pull to get doctors to do their bidding. If your doctor refuses the test or consultation you think you need, don’t run to file an appeal with the plan. ““You want help from your doctor, not a decision from a clerk in a health plan,’’ says Dr. Vincent Riccardi of American Medical Consumers, an independent patient-advocate service in La Crescenta, Calif. Ask the doctor to spell out your treatment plan, describe the benefits and risks and outline alternatives. Then ask for a summary in writing.
Do Your Homework: The most powerful step you can take is to learn everything you can about your condition or disease. ““Too often doctors don’t know what the best course of treatment is,’’ says Peter Lee, a director at the Center for Health Care Rights in Sacramento, Calif. Look for hospitals, associations and medical libraries to steer you to the right resources. Health Finder, on the Web (www.healthfinder.gov), is a terrific first stop. Getting smart may also mean consulting a nonplan doctor. Go to the most respected expert you can find. It will cost some money, but may save you more in the long run. If you later decide to appeal your HMO’s decision on your treatment, his opinion will be hard to ignore.
Find an Advocate: By all means file a grievance or formally appeal your plan’s judgment if you need to. But don’t stop there. ““Remember, the appeals process is being run by the same people who denied you the care in the first place,’’ warns Jacqueline Fox, a Washington, D.C., attorney. Recruit advocates for your cause. One of the most influential is your employer, because it pays the HMO’s bills. Ask your benefits manager or your boss to call or write the plan’s medical director and marketing director on your behalf. Other places to turn: your insurance broker, regional advocacy groups, state departments of insurance. If you’re sick, you should also appoint a family member or close friend to deal with the plan.
There’s also a brand-new avenue for dissatisfied HMO members. A handful of companies dedicated to giving consumers independent medical advice have sprung up recently. CareCounsel in San Rafael, Calif. (888-227-3334), will conduct a quality review of your cancer treatment in conjunction with oncologists at Memorial Sloan-Kettering Cancer Center. American Medical Consumers in La Crescenta, Calif. (800-836-5262), counsels subscribers about picking doctors and specialists and choosing appropriate treatment. By the year-end Health Decisions Inc., in Golden, Colo. (303-278-1700), will be offering advice on surgery, prenatal care, disease management and changing unhealthy habits. It’s a shame to have to pay someone else for expertise that your health plan should provide. But it’s better than doing nothing.
